Minimally invasive cardio-surgery

Health and Culture Quarterly • RESEARCH – Policlinico San Donato
DR. Alessandro GIAMBERTI

513 1When we talk about cardio-surgery, the first thought is obviously about the delicacy of the operation, about the necessity to “stop” the heartbeat, about the surgeon who touches the most vital part of our body with a scalpel. A scar on the sternum will be a reminder of that moment forever, a tattoo that life has engraved on the skin. Nowadays, the progression of surgical technique and the development of treatments enable the aesthetic point of view of a heart operation to be taken into consideration as particularly for patients who have yet to become adults. At IRCCS Policlinico San Donato, an Italian and European centre of reference for cardio-surgery and cardiology for congenital pathologies, which therefore affect patients of paediatric age, a minimally invasive cardio-surgery technique has been developed that enables the aesthetic impact of the intervention to be limited. We are discussing this with Doctor Alessandro Giamberti, director of the Cardio-Surgery for Congenital Pathologies Operating Unit at Policlinico San Donato, the only cardio-surgeon in Italy to use the right medial-axillary approach.


Doctor Giamberti, is medial-axilary cardiac intervention something new within the famework of congenital cardiopathies?

“Not exactly. I wrote the first study on minimally invasive cardio-surgery in Italy at the end of the nineteen-nineties. At that time, we used the sub-mammary route, making an incision at right-breast level, under the nipple. The impact on boys was not so evident, but it could create problems for girls. If the intervention was carried out at a pre-adolescent age, when breast development had not yet taken place, the scar could lead to abnormal growth, with visible asymmetry. What is new is right medial-axillary access, i.e. making an incision laterally to the ribs, under the armpit. The vertical scar is covered by the arm.”


What changes from a surgical point of view?

“Nothing. Assessing the result of the intervention, there is no difference relative to the traditional access by opening up the sternum. In fact, by avoiding fracturing the bone and entering between the ribs without breaking them, a faster and less painful post-operative recovery is posible. The young patient can therefore be discharged 4-5 days after the intervention, with the maximum result and the minimum discomfort.”

How important is the aesthetic impact?

“Very important. A little girl who is not very old will not think so now, but a visible scar is an element that could cause psychological distress in time. Just a few months ago, I operated on a beautiful nine year-old girl from Rome. Her parents were worried about the scarring as well as the intervention. They found out about this new minimally invasive cardio-surgery technique through their attending cardiologist, and approached us at Policlinico San Donato. The intervention was a complete success – there is a scar, but it cannot be seen because it is entirely covered by the arm.”

How was the surgical team formed?

“We started a collaboration with one of the foremost experts in Europe, the Swiss cardio-surgeon René Prêtre, a professor at the University of Lausanne, who we hosted at Policlinico San Donato, and who demonstrated his approach to us. Through operating together on patients within different age groups, we learned and then replicated the technique. The initial results were extraordinary.”

What pathologies can this technique be used for?

“It is an approach that originates from the correction of atrial septal defects, but we are broadening its use for the treatment of other cardiopathies as well, such as partial atrioventricular canal, partial anomalous pulmonary venous return, and minor ventricular septal defects. The results were so satisfactory that we started extending the various minimally invasive techniques to adult patients suffering from congenital cardiopathies as well.”

Why can interventional cardiology not be used for these patients, where is it less invasive?

“Not all congenital cardiopathies can be resolved via the percutaneous route (Editor’s note: i.e. with the insertion of catheters and small corrective devices through arteries and veins) without recourse to “open-heart” surgery. In the specific case of atrial septal defects, the primary approach is definitely percutaneous: within Policlinico San Donato, the Paediatric and Adult Congenital Cardiology Operating Unit, led by Doctor Mario Carminati, is one of the principal centres in Europe with regard to the number and complexity of interventional procedures. Only 30 percent of children born with an atrial septal defect get to see a surgeon, because of anatomical conformation, technical limitations or the characteristics of the defect, it is not possible to correct it through insertion of a so-called “umbrella”. We intervene surgically in these cases, inserting a “patch” (Editor’s note: a patch made of biological material similar to that of the heart), which is sutured on and lasts indefinitely. Thanks to this new approach using a medial-axillary incision, we are finally able to operate in a less disfiguring way, with the same excellent results.”


ATRIAL SEPTAL DEFECT (ASD): Communication within the wall that should separate the left and right atria completely. In more severe forms, the wall is entirely absent. It is the simplest form of congenital cardiopathy, but if not treated, it can lead to cardiac insufficiency and arrhythmias over the course of the years.
VENTRICULAR SEPTAL DEFECT (VSD): Communication within the wall that should separate the left and right ventricles completely. In more severe cases, cardiac insufficiency may be manifested, due to an increase in blood pressure within the pulmonary artery.
ATRIOVENTRICULAR CANAL DEFECT: Defect in the formation of the central part of the heart, both within the mitral and tricuspid valves, and within the septum that divides the atria and the ventricles. It can be partial, the mildest form, or complete. It is resolved by closing atrial and ventricular septal defects, and correcting the structure of the mitral valve.
ANOMALOUS PULMONARY VENOUS RETURN: Malformation of the pulmonary veins wherein, instead of being connected to the left atrium, they are connected to the right side of the heart. Oxygenated blood is therefore largely returned to the lungs.
Date: 01/07/2019
By: Nicole Colusso
Translation: TDR Translation Company
Editing: Victor Cojocaru